Jipmer Quality Council

JQC Monthly meetings will be held every month with Director as chairperson to discuss the previous month activities and to decide the activities to be done in the coming month. The group leader will not only present their group activities for knowledge of other members but also get critical appraisal and feedback from them.

The implementation steps will be: engagement of stakeholders, creating a multidisciplinary structure (e.g. Floor based team building/cohorting, restructure hospitalist role/enhancing ownership), redesigning process flow (e.g. Concurrent multidisciplinary rounds), using appropriate tools of the trade. The integrated Multidisciplinary team will be created for human factor engineering to train health care workers at various levels.

The tools of the trade are multidisciplinary rounding tool, Handoff tool (between shifts and hospital domains), Bedside Clinical Decision Support devices and Simulators for Procedures and physiologic scenarios. The care processes to be developed are structured rounds, checklists, care pathways, Interdisciplinary protocols ( eg. Upper Gastrointestinal Bleed) and scoring systems. The analytics to be used are Departmental morbidity and mortality reviews (with emphasis on root cause analysis models), Hospital reviews for mortalities, near misses, adverse events, sentinel events and never events. Common formats for defining and reporting adverse events will be developed. Intra-institutional blames free real-time electronic error reporting systems will be developed with the collaboration of software designing experts. National level Guidelines for the de-identified database for hospital wise events and glossary of reported medical errors will be formulated.

Objectives

To develop hospital quality paradigm using patient safety as the central domain at JIPMER

To formulate the Key Performance Indicators (KPIs) for general adoption for improving

To play a lead role in creating integrated model of Patient safety and quality at regional and national level and develop Health care quality leadership training and patient safety institute

Structure of JIPMER Quality Counicil(JQC)

Founder president/ Chairman

Dr Subhash Chandra Parija, Director, JIPMER

Member secretary and Group Co-ordinator

Dr Muruganandham K, Assistant Professor of Urology, JIPMER

Co-ordination committee

Dr. Anita Rustagi, DMS, JIPMER

Dr Gitanjali, Professor of Pharmacology

Dr Muruganandham K, Assistant professor of Urology

Ms. Vasantha, Nursing superintendent, JIPMER

Finance officer, JIPMER

Members of JIPMER Quality Council

(Members in groups 1 to 6 will reassemble to form Groups 7 to 12; each member of JQC will be working in two groups at each time.)

Members of JIPMER Quality Council

Group 1

Group 2

Nosocominal infection

Medication

Dr Rakhi, Microbiology

Prof. Gitanjali, Pharmacology

Dr Devi Prasad Mohapatra, Plastic surgery

Dr S. Manikandan, Pharm

Dr B.V. Sai Chandran, CTVS

Dr Biswajith Dubashi, Medical Oncology

Dr Murali Poduval, Orthopedics

Dr Vaibhav Wadwekar, Neurology

Dr Jayaprakash Sahoo, Endocrinology

Dr Ravi Philip Rajkumar, Psychiatary

Dr Narayanan P, Pediatrics

Dr Rashmi Kumari, Dermatology

Dr Muruganandham K, Urology

Dr Chanaveerappa Bammigatti, Medicine

Mrs S. Sushya Tech, Pathology

Dr. Kesavan, Pharmac

Mr.K. Allimuthu, Tech, Microbiology

Mr Saravanan, Tech, Dialysis

Komathy.S, Nursing, 46 WD

Daisy.D, Nursing, ICU-32

Group 3

Group 4

EMSD

Accreditation

Dr Nandha Kishore, Surgery

Dr M.S. GopalaKrishnan, Neurosurgery

Dr Sarasu Jayaraman, Anatomy

Dr Satyen Parida, Aanesthesiology

Dr B. Krishnan, Dentistry

Dr Bibekanand Jindal, Pediatric Surgery

Dr P. Veena, O&G

Dr Manju, Pulm Medicine

Dr Arvind Ramkumar, Surg Onco

Dr K. Ramesh Babu, Ophthal

Dr Rakhee Kar, Pathology

Dr Biju. P, Surgical Gastroenterology

Sivaranjani.K, Nursing , EMSD

Ms. Vanitha, Nursing, Uro OT

Mr. Dinakaran, Nursing, Gastro OT

Mr Sundaramurthy, Tech, Path

Mr. Senguttuvan, Tech, Path

Muthukumarasamy, MRD

Mrs V Chitralekha, Social welfare officer

Mr. Venkatraman A,Tech, Biochem

Group 5

Group 6

Fire safety/ Disaster management

Work place/work force safety

Dr Shyama Prem, Radiotherapy

Dr Lakshmi. P , Med Gastro

Dr Dhanpathi.H, Nuclear medicine

Dr Arun Alexander, ENT

Dr Deepak Bharathi, Radiology

Dr Santhosh Satheesh, Cardiology

Dr Swaroop, PSM

Dr Sreejith P, Nephrology

Dr G.S. Gaur, Physiology

Dr K.K. Shaha, Forensic Medicine

Dr Anita Rustagi, I/C MRD

Dr Dasari Papa, O& G

Mr K Saravanan, Lecturer, Department of Radiotherapy

Dr Medha. R, Biochem

Mr Ramkumar(auditorium I/C)

Dr Vijayaprabhu, Radiotherapy

Mr K Anand, Nursing, Transplant ICU

Mrs. Angelin Mary Sheela, Nursing college

Mr Rajasekar, Tech, Radiology

Mr Gnansekhar, Tech, Blood bank

Ms S Gobalakichenin, Tech, Biochem

Ms. Catherine, Nursing, EMSD

Mr Chinnapparaj, Stores officer

Ms Durgadevi T, Tech, Biochem

Group 7

Group 8

Never events

Operation room safety

Dr Narayanan, Pediatrics

Dr Murali Poduval, Ortho

Dr Veena, O&G

Dr Satyen Parida, Aanesthesiology

Dr Chanaveerappa Bammigatti, Medicine

Dr Deviprasad, Plastic surgery

Dr B.V. Sai Chandran, CTVS

Dr Arun, ENT

Dr Nandha Kishore, Surgery

Dr Rakhi, Microbiology

Dr M.S. GopalaKrishnan, Neurosurgery

Dr Jindal, Pediatric Surgery

Dr Medha.R, Biochem

Mr Sundaramurthy, Tech, Path

Mr. Dinakaran, Nursing, Gastro OT

Mr Rajasekar, Tech, Radiology

Ms. Vanitha, Nursing, Uro OT

Ms. Vanitha, Nursing, Uro OT

Mrs S. Sushya Tech, Pathology

Group 9

Group 10

SOP/Checklist/Communication

Blood/Injection

Dr Biju P, Surgical Gastroenterology

Dr Biswajith Dubashi, Med Onco

Dr Vaibhav Wadwekar, Neurology

Dr Lakshmi. C. P, Med Gastro

Dr S. Manikandan, Pharm

Dr Manju, Pulm Medicine

Dr Sreejith, Nephrology

Dr Rashmi Kumari, Dermatology

Dr Arvind Ramkumar, Surg Onco

Dr Shyama Prem, Radiotherapy

Dr Rakhee Kar, Pathology

Dr Muruganandham K, Urolog

Mr K Anand, Nursing, Transplant ICU

Mr Gnansekhar, Tech, Blood bank

Muthukumarasamy, MRD

Komathy.S, Nursing, 46 WD

Mrs. Angelin Mary Sheela, Nursing college

Dr. Kesavan, Pharmacy

Ms Durgadevi T, Tech, Biochem

Ms. Catherine, Nursing, EMSD

Group 11

Group 12

Sentinel events/Root cause analysis

Radiation safety

Dr Santhosh Satheesh, Cardiology

Mr K Saravanan, Lecturer, Radiotherapy

Dr Jayaprakash Sahoo, Endocrinology

Dr Swaroop, PSM

Dr Sarasu Jayaraman, Anatomy

Dr Dhanpathi.H , Nuc medicine

Dr Ravi Philip Rajkumar, Psychiatry

Dr B. Krishnan, Dentistry

Dr K. Ramesh Babu, Ophthal

Dr G.S. Gaur, Physiology

Dr K.K. Shaha, Forensic Medicine

Dr Anita Rustagi, I/C MRD

Prof Gitanjali, Pharmacology

Dr Deepak Bharathi, Radiology

Dr Vijayaprabhu, Radiotherapy

Mr. Senguttuvan, Tech, Path

Mr Saravanan, Nursing, Dialysis

Mr.K. Allimuthu, Tech, Microbiology

Ms S Gobalakichenin, Tech, Biochem

Sivaranjani.K, Nursing , EMSD

Daisy.D, Nursing, ICU-32

Mrs V Chitralekha, Social welfare officer

Mr Chinnapparaj, Stores officer

Activities of JQC ( As on 31st December 2012)

Deliverable

Group

November and December

January

Group 1Nosocominal Infection

Conducted infrastructure survery

Created Pocket Guide for Hand washing

Analysis of infrastructure survey

Printing and circulating the pocket guide for hand wash

To bring out 2nd edition of Rational use of antibiotics at JIPMER

Group 2Medidcation safety

Draft template for C-slip circulated to JQC and comments receivedJIPMER Press contacted and agrees to print books for pilot testing of C-slipsC-slip template modified & finalized; logistics of implementation worked outPharmacy agrees to accept only one prescription with original signatureOne concept proposal sent to Department of Health Researchfor funding a project on medication safety

Pilot testing to start by mid-JanStart with Medicine, Dermatology, Neurology, Medical oncology,psychiatryInform the clinical faculty and residents during death meeting and through emails Interns Orientation Program – sensitize the interns

Created a model of Root cause analysis at Mortality andMorbidity meeting and piloted at Cardiology

To create electronic errorreporting systemCirculation of JIPMER specific Model of Root cause analysis to all JQC members for input and finally take to all departments

Group 12Radiation safety

Formulated a radiation safety committee and the first meeting of the committee was conducted on 09 Nov 2012.Radiation Survey has been in all diagnostic installations in Radio-diagnosis.Identified that two of the installation was not meeting the basis safety requirement. Necessary steps have been taken to restore safety.In Nuclear Medicine the Annual Status Report on Radiation Safety for the year 2012 has been prepared and submitted to AERB.Thirteen application for availing Personnel MonitoringBadges to staff working in radiation field has been processed and the badges will be provided to them shortly.In Radiotherapy the Annual Status Report on Radiation Safety for the year 2012 is under process and will be submitted to AERB shortly

Radiation Survey will be performed in the diagnostic unit of urology OT.Dental X ray unit in minor OT is also being used as office and stores and rest room for residents. This puts the office and paramedical staff in risk to exposure to radiation. A radiation survey will be performed and appropriate recommendations will be given.Bone densitometer and gamma irradiator are yet to be installed due to lack of space.